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Lee's Summit Underwater Rescue and Recovery
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David Hartman
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LETTER OF INTEREST
Please fill in this form and press "submit" if you are interested in joining the Team.
Diver candidate:
Support Candidate:
Name:
Address:
Address2:
City, State, Zip
AK
AL
AP
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Home Telephone
Work Telephone
Mobile Telephone
E-Mail
Date of Birth
"MM/DD/YYYY"
Spouse's Name
Emergency Contact
Emergency Contact #
Current Employer
Ocupation
EXPERIENCE
Mark all that apply
Name
Certified
Agency
Expiration
CPR
CPR Trainer
Lifeguard
Para-Medic
First Aid
Name
Active
Department
Public Safety Officer
Fire Professional
CORE DIVING CERTIFICATIONS
Please complete the following fields if you are a Diving Candidate only.
CERTIFICATION LEVEL
AGENCY
STUDENT #
YEAR OBTAINED
IANTD
NACD
NASDS
NAUI
PADI
PSSI
SSI
YMCA
DoD
Dive Rescue Intl
Advanced Open Water
Rescue Diver
Dive Rescue I
Dive Rescue II
PSSI
DiveMaster
Instructor
Military
Commercial
IANTD
NACD
NASDS
NAUI
PADI
PSSI
SSI
YMCA
DoD
Dive Rescue Intl
Advanced Open Water
Rescue Diver
Dive Rescue I
Dive Rescue II
PSSI
DiveMaster
Instructor
Military
Commercial
IANTD
NACD
NASDS
NAUI
PADI
PSSI
SSI
YMCA
DoD
Dive Rescue Intl
Advanced Open Water
Rescue Diver
Dive Rescue I
Dive Rescue II
PSSI
DiveMaster
Instructor
Military
Commercial
IANTD
NACD
NASDS
NAUI
PADI
PSSI
SSI
YMCA
DoD
Dive Rescue Intl
SPECIALTY CERTIFICATIONS
CERTIFICATION LEVEL
AGENCY
STUDENT #
YEAR OBTAINED
Cave - Full or Apprentice
Cavern
Night
Wreck
Ice
Deep Air
Deep Mixed Gas
Altitude
Photography
Dry Suit Diving
U/W Communications
Nitrox
IANTD
NACD
NASDS
NAUI
PADI
PSSI
SSI
YMCA
NSS-CDS
Dive Rescue Intl
Cave - Full or Apprentice
Cavern
Night
Wreck
Ice
Deep Air
Deep Mixed Gas
Altitude
Photography
Dry Suit Diving
U/W Communications
Nitrox
IANTD
NACD
NASDS
NAUI
PADI
PSSI
SSI
YMCA
NSS-CDS
Dive Rescue Intl
Cave - Full or Apprentice
Cavern
Night
Wreck
Ice
Deep Air
Deep Mixed Gas
Altitude
Photography
Dry Suit Diving
U/W Communications
Nitrox
IANTD
NACD
NASDS
NAUI
PADI
PSSI
SSI
YMCA
NSS-CDS
Dive rescue Intl
Cave - Full or Apprentice
Cavern
Night
Wreck
Ice
Deep Air
Deep Mixed Gas
Altitude
Photography
Dry Suit Diving
U/W Communications
Nitrox
IANTD
NACD
NASDS
NAUI
PADI
PSSI
SSI
YMCA
NSS-CDS
Dive Rescue Intl
PERSONAL DIVING EXPERIENCES
Describe your
best
dive:
Purpose of this dive:
LOCATION
CURRENT
GAS USED
VISIBILITY
MAX DEPTH
Bay
Lake
Ocean
Pond
Quarry
River
Spring
None
Low
Medium
Strong
Air
Nitrox 32%
Nitrox 36%
Trimix
Nitrox Custom
None
0-5'
10-25'
75-100'
100+
0-50'
51-100'
101-150'
151-200'
201-250'
251-350+
Describe your
worst
dive:
Purpose of this dive:
LOCATION
CURRENT
GAS USED
VISIBILITY
MAX DEPTH
Bay
Lake
Ocean
Pond
Quarry
River
Spring
None
Low
Medium
Strong
Air
Nitrox 32%
Nitrox 36%
Trimix
Nitrox Custom
None
0-5'
10-25'
75-100'
100+
0-50'
51-100'
101-150'
151-200'
201-250'
251-350+
Describe your
most technically challenging
dive:
Purpose of this dive:
LOCATION
CURRENT
GAS USED
VISIBILITY
MAX DEPTH
Bay
Lake
Ocean
Pond
Quarry
River
Spring
None
Low
Medium
Strong
Air
Nitrox 32%
Nitrox 36%
Trimix
Nitrox Custom
None
0-5'
10-25'
75-100'
100+
0-50'
51-100'
101-150'
151-200'
201-250'
251-350+
REFERENCES
Please let us know of a few people who can discuss your diving and personal values with us.
Name:
Telephone:
Name:
Telephone:
GENERAL QUESTIONS
How will the Dive Team benefit from your membership?
What tasks of diving make you most uncomfortable?
Any prior experience working with Public Safety agencies?
This is not a dive club. When a call for assistance comes out, each person is depended upon to respond when not at work. Are you willing to be on-call 24 hours a day 7 days a week, except hours at work?
Answer?
Yes
No
Comments:
When you select the "Submit" button below, your "Letter of Interest" will be sent to the Diving Control Board" for review and follow-up. You should expect to have a response, either via e-mail, telephone, or post within a week. If not, please re-submit this form.
Thank you!
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